This document discusses principles for managing acute infection after operative fracture fixation. It notes an infection rate of 1-2% for closed fractures and 6-7% for open fractures. Risk factors for surgical site infection include older age, comorbidities, drugs, prior infections, and emergency operations. Factors contributing to acute infection include contamination, a medium for bacteria to grow, mechanical instability, and dead soft tissues. Strict protocols around cleaning, masking, handwashing, and isolating MRSA patients can reduce contamination risk. Careful surgical technique, debridement, hemostasis, and temporary fixation can address other risk factors. Signs of acute infection include swelling, pain, fever and elevated inflammatory markers. Aggressive wound revision

1. AOTrauma Principles Course
Management of acute infection after
operative fracture fixation
Thomas P Rüedi, CH

2. “The risk of infection remains the crucial
issue of internal fixation”—Martin Allgöwer, 1975
Today, 30 years later, this statement is still valid!

3. An incidence of infection
• > 1–2 % for closed fractures
• > 6–7 % for open fractures
(except Gustilo type IIIB & IIIC)
• Requires action to revise the
protocol of your fracture
management
P Ochsner 1992, Gustilo et al 1987

4. Risk factors for surgical site infection
Host related:
• Older age
• Co-morbidity
(diabetes, obesity,
arteriosclerosis, malnutrition,
nicotine, etc)
• Drugs (steroids, immuno-
suppression, antibiotics)
• Remote infections (dental, etc)
• Preoperative hospitalization
Procedure related:
• Emergency operation
• Duration of surgery
• Surgical technique
• Timing of surgery

5. Factors contributing to acute infection
• Contamination with pathogenic organisms
• Staphylococcus aureus > 64%
• Presence of a medium for bacteria to grow
• Rough soft-tissue handling, periosteal stripping
• Mechanical instability of fracture
• We can influence all of them
Acute posttraumatic infection
starts locally with or without
general symptoms

6. How to reduce the risk of contamination
• Staphylococcus aureus are everywhere in our hospitals
• Discipline in patient management is essential:
- good cleaning of our hospitals
- wearing face masks
- repeated hand disinfection―mandatory to disinfect
hands for each patient contact
- type and time of hair removal
- correct skin disinfection
- no “small talk” during surgery
- sterile gloves for dressing changes
Strict isolation if MRSA (methicillin-resistant
Staphylococcus aureus)is suspected (referrals)

7. Soft-tissue care
• Up to the closure of the wound the soft tissues must be
handled with greatest care
Poor surgery

8. Influences on bacterial growth
• All bacteria require a medium with which to grow.
• The commonest medium following ORIF is a
haematoma, seroma or fluid collection around an
implant.
• Such a medium can be reduced by meticulous
haemostasis and the use of suction drains.
• The surface structure of an implant is also critical when
determining the critical size of an innoculum which will
result in an infection.

9. Influences on infection―dead soft
tissues
• Skin necrosis can be prevented by not closing wounds
that are too tight.
• Damage to muscle and periosteum can be reduced by
meticulous surgical technique—in open cases, careful
debridement of all necrotic tissue is vital.
• Thermal damage can be caused either by cauterization
or occasionally by drilling.
• Reduce thermal damage by ensuring drill tips are sharp
and lubricated.

10. Influences on infection―dead hard
tissue
• Devascularized bone and foreign bodies are good
culture media for bacterial growth.
• Risk of infection can be minimized by excising all
devascularized bone and removing all foreign bodies.
• Adequate debridement in an open fracture is the most
important surgical maneuver in the prevention of
infection.

11. Clinical signs of acute infection
Local:
• Swelling
• Inflammation
• Tenderness/pain
• Fluctuation
If in doubt  agressive wound revision
General:
• Fever
• CRP (C-reactive protein)
• Leucocyte

12. Wound revision in acute infection
• Wash-out with lots of fluid (+/- antibiotics) > dilution
• Debridement (repeated) of all dead tissue, fibrin or pus
• Checking stability of fixation and implants:
- To be improved if inadequate
• Gentamycin beads? antibiotic sponges?
• Wound closure depending on local situation
• Temporary bedrest (2–3 days)
• Antibiotics for 6 weeks (according to culture test)

13. 22-year-old, motorbike accident
Gustilo type II open femoral fracture 32-C3
• Initially 3 weeks in traction,
then 2 plates elsewhere!

14. 1 week postoperatively
• Transferred to us, suspicion
of gas gangrene?
• Repeated wide
debridement, lavage, open
wound care, no change of
fixation

15. Infection and implants of fracture fixation
• Although you should leave in fixation devices in fractures
that are stably fixed
• Be aware that infection is a common cause of loosening,
especially of screws
• Almost 50% of implants need to be removed in
established deep infections, even if the implants were
stable at the time of first diagnosis of infection

16. 22-year-old man, motorbike accident,
Gustilo type II open femoral fracture 32-C3
• 8 weeks after injury
clean wound
• Splitskin graft, signs of
callus and sequestra
• 16 weeks: medial
bridge?
• Reoperation to remove
sequestra and the 2
plates
• New plate, because of
persisting instability

17. 22-year-old man, motorbike accident,
Gustilo type II open femoral fracture 32-C3
• Uneventful healing, immediate active motion & ambulation
• 39 weeks: follow-up with good function, full weightbearing,
• Implant removal after 18 months
• Result after 2 years, back to work and sports, muscle
herniation

18. Infection and implants for fracture
fixation
• Any implant/device providing mechanical stability should
stay in place
• Loose implants must be removed or replaced to optimize
the fixation
• A rigidly fixed fracture will unite in spite of infection
W W Rittmann & S Perren, 1974

19. 19-year-old man, motorbike accident,
Gustilo type IIIB open distal tibial fracture
43-B2
• Emergency ORIF (open reduction and internal fixation)
with dorsal plate, debridement, open wound care, leg in
suspension
• Planned secondary
bone graft

20. 19-year-old man, motorbike accident,
Gustilo type IIIB open distal tibial fracture
43-B2
• Delayed wound
healing, clinical
signs of infection,
lack of stability
• After 7 weeks
decision to
increase stability
by adding anterior
plate
• Wound revision
and bone graft

21. 19-year-old man, motorbike accident,
Gustilo type IIIB open distal tibial fracture
43-B2
• 34 weeks later
solid callus bridge,
no signs of
infection
• 2 years after
accident and
implant removal,
very good
function, no pain

22. Role of antibiotics in fracture surgery
Prophylactic antibiotics reduce risk of contamination:
• Perioperative (before tourniquet!)
• Single dose (1st/2nd generat. Cefalosporin) max. 24
hours
Burke JF 1961, Surgery
• Prophylactic antibiotics are not a substitute for a
careful surgical technique
Bodoki et al l993,
Boxma et al 1996

23. Summary
• Incidence of infection after operative fixation of closed
fractures should be < 1-2%
• Appropiate “behaviour” helps to reduce the risks
• In case of acute infection immediate action is mandatory
• Thorough debridement of all dead tissue
• Implants providing stability may remain “in situ”
• Mechanical stability and vital tissues are essential to
obtain bony union
• Prophylactic single dose antibiotics are effective, but
cannot replace poor surgery

24. Albin Lambotte in 1902
“Opening the site of a fracture is not serious provided that
one avoids surgery of contused tissue, bruised and
infiltrated with blood and generally disposed to invasion by
pyogenic germs.
All that creates the danger of infection is bad surgery,
where the surgeon, uncertain of his technique fumbles and
at length infects all recesses of the wound with his fingers.
This danger is avoidable and must be averted. Before
taking the scalpel the surgeon planes his task in detail, so
to perform the operation rapidly and precisely without
creating additional damage”.